COPD with tension pneumothorax

 

Scenario Objectives

Identify signs and symptoms of COPD exacerbation

Develop and implement treatment plan for COPD exacerbation

Recognize and respond to common complications of COPD exacerbation and treatment

Review pathophysiology of acute COPD exacerbation

Equipment Required

Oxygen deliver: NRB, Nebulizer, BVM, BiPAP, BVM

Laryngoscope, ET tube

Beta agonists

IV, IV fluids

14G needle for chest decompression

Lecture/Educational Notes

Initial decision making in management should account for patient’s mental status, degree of reversible bronchospasm, prior history of exacerbations (hospitalizations and intubation), specific causes or complications of exacerbation.

Predict and prepare for a physiologically difficult airway

Hypoxemia

Metabolic acidosis

Hypotension

RV failure

DOPE for a patient who begins to deteriorate on a ventilator

Patients with existing emphysema are at at risk of developing pneumothorax

CXR or U/S can be used to rapidly identify a pneumothorax

Pathophysiology:

Common causes of exacerbation are infection or airway irritant.

Inflammation leads to bronchoconstriction and increased mucus secretions.  This causes a V/Q mismatch to occur, which is the primary underlying cause of hypoxemia.

Breath stacking can lead to increased intrathoracic pressure, barotrauma, or obstructed venous return.

References

Mosier, J. M., Joshi, R., Hypes, C., Pacheco, G., Valenzuela, T., & Sakles, J. C. (2015). The Physiologically Difficult Airway. Western Journal of Emergency Medicine, 16(7), 1109–1117. http://doi.org.ezproxy.pcom.edu:2048/10.5811/westjem.2015.8.27467

Bates CG, Cydulka RK. Chapter 73. Chronic Obstructive Pulmonary Disease. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds.Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e New York, NY: McGraw-Hill; 2011. http://accessmedicine.mhmedical.com.ezproxy.pcom.edu:2048/content.aspx?bookid=348&sectionid=40381539. Accessed May 09, 2018.

Patient Demographics

62 year old male

HPI

Has been experiencing increasing shortness of breath since yesterday, but refused family’s request for medical attention.  Was brought to ER by family when he became unable to stay awake.

PMH/Home medications

PMH: COPD  Meds: Home O2, Atrovent, Sertraline, Spiriva,

Initial Physical Exam

Alert to painful stimuli.  Cyanotic, pursed lip breathing, increased work of breathing with accessory muscle use.  Lung sounds diminished in all fields.  No peripheral edema.  Heart sounds +S1 +S2.

Pertinent Labs

BGL (116 mg/dl), CBC (WBC 12,500, Hb 16 Hct 48, Plt 200K) BMP (Na 140, K 3.5, Cl, 100, Cr .85, BUN 16, HCO3 29) ABG (pH 7.26, pCO2 60, pO2 44 HCO3 29)

Pertinent Imaging/Tests (including U/S, EKG, etc.)

EKG, CXR, U/S

Signs/Symptoms/Description

Rhythm

Vital Signs

Action to Progress

Teaching Objectives

1

Obtunded, Respiratory distress

Sinus tachycardia

Eyes: open to pain

HR: 110

BP:120/56

RR:6

%O2:73

EtCO2: 98

T:37

Provide O2, medication, and select appropriate airway management strategy

Recognize need to rapidly control breathing in a patient with COPD exacerbation and decreased level of consciousness

2

Tension pneumothorax left lung

Sinus bradycardia

Eyes: closed

HR: 44

BP: 57/29

RR: Intubated

%O2: 82

EtCO2:

T: 37

Decompress chest. Proceed to 4 if they recognize the pneumothorax and treat within 3 minutes.  

If failure to recognize pneumothorax proceed to 4

Recognize potential complication of intubation and PPV in a patient with emphysema.

Clinical and imaging findings to diagnose tension pneumothorax

Employ DOPE for deterioration on ventilator

3

Recovery

Normal sinus

Eyes: closed

HR: 88

BP: 110/56

RR: Intubated

%O2: 96

EtCO2: 31

T: 37

 Request labs and determine patient disposition (ICU admission), end scenario and debrief.

Select appropriate labs and imaging for further management of patient

4

Cardiac arrest

Sinus bradycardia PEA

Eyes: closed

HR: 0

BP:0

RR: Intubated

%O2: 0

EtCO2: 7

T: 37

Initiate CPR.  If pneumothorax recognized within 2 minutes proceed to 4.  If not end scenario and debrief

  Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 13254

Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 13254